Provider Demographics
NPI:1356817464
Name:GONZALEZ, IVETTE
Entity Type:Individual
Prefix:
First Name:IVETTE
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MACKEY RD
Mailing Address - Street 2:
Mailing Address - City:GARNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10923-1810
Mailing Address - Country:US
Mailing Address - Phone:718-828-2666
Mailing Address - Fax:
Practice Address - Street 1:16 MACKEY RD
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923-1810
Practice Address - Country:US
Practice Address - Phone:718-828-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143242164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse